Are you experiencing pain in your Hip(s) or Knee(s)?
Yes No
a.
If yes, where is your pain?
Hip Knee
2.
Is the pain in your knee or hip joints tolerable but limiting to your ordinary activity or work?
Yes No
3.
Does the degree of pain and discomfort sometimes require medication stronger than aspirin?
Yes No
4.
Are the symptoms present more than half the time during a typical month?
Yes No
5.
Do you have pain in your knee or hip when climbing stairs without using the railing?
Yes No
6.
Are you forced to stop when you walk more than two or three blocks due to pain?
Yes No
7.
Do you ever use walking aids, such as a cane or walker to assist you with walking?
Yes No
8.
Do you walk with a moderate limp?
Yes No
9.
Do you feel some pain even when you are sitting or lying down?
Yes No
10.
Does your knee or hip sometimes give out when you are physically active?
Yes No
If you answer yes to even one of these questions, you may be a candidate for total joint replacement surgery. Please call 713-222-CARE (2273) for a referral to one of the joint replacement specialists associated with Memorial Hermann Southwest.
